自分用ノート：Musculoskeletal

勉強ノート

Neck pain

Fibromyalgia

Strain vs. Sprain = Tendon vs. Ligament

Achilles tendon disorders

Ankle sprain

Testing (physical exam) for Sprain

Image Testing (radiology) for tendon, ligament, fascia

 

Neck Pain

Younger people tendency

  • axial neck pain – non-specific neck pain due to mechanical or postural injury
  • myofascial pain – muscle injury
  • fibromyalgia
  • disc herniations

Older people tendency

  • foraminal stenosis – due to cyst or tumor
  • uncovertebral hypertrophy – swelling of the uncovertebral joint
  • cervical stenosis
  • disc herniations
  • axial neck pain

Radiculopathy r/t disc herniation gets better up to 90% with non-surgical treatment.

Treatment

  • spinal manipulation with high-velocity and low-amplitude manual thrust
  • Spinal mobilization techniques
  • Modalities – ice, heat, electrical stimulations, laser therapy
  • Traction
  • Exercise
  • Pharmacologic management – acetaminophen, NSAIDs, muscle relaxant (tizanidine, cyclobenzaprine, baclofen), analgesics, corticosteroid injection

 

Fibromyalgia syndrome

 

Diagnostics

  • Lab類はほぼどれも正常値。確認の為に「CBC, CMP, TSH, ESR, CRP」。
  • Imaging – 不要
  • 追加検査でANA, RF, ACPA – synovitis (synovial swelling or inflammation) が見られる時のみ。Only。 (Buttaro et al., 2021)

Conditions with (+) ANA

  • Systemic Lupus Erythematosus (SLE)
  • Sjogren’s syndrome – destroy exocrine glands
  • Scleroderma – systemic sclerosis
  • Myositis/polymyositis
  • Rheumatoid Arthritis (RA)
  • Psoriasis Arthritis
  • Others

(Nosal et al., 2022)

Conditions with (+) Rheumatoid Factor (RF)

  • Rheumatoid Arthritis (RA)
  • Cancers (some)

Conditions with (+) Anti-citrullinated protein antibodies (ACPAs) – can predict bone erosion/destruction

  • Rheumatoid Arthritis (RA)

(Liu et al., 2022)

 

Pharmacological Treatment for Fibromyalgia

  • FDP-approved – Tricyclic drugs – amitriptyline 10mg QSH, Cyclobenzaprine 5-10mg QSH
  • FDA-approved – SSRI – fluoxetine (Prozac), duloxetine (Cymbalta), milnacipran (Savella)
  • Gabapentin (Neurontin), pregabalin (Lyrica) – for pain
  • Zolpidem (Ambien), trazodone (Desyrel) – for sleep

(Buttaro et al., 2021)

Non-pharmacological approach

  • CBT/Cognitive Behavioral Therapy
  • Exercise – ちょっとずつ
  • Massage, acupuncture

 

Reference

Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care. Interprofessional collaborative Practice. Elsevier

Liu, J., Gao, J., Wu, Z., Mi, L., Li, N., Wang, Y., Peng, X., Xu, K., Wu, F., & Zhang, L. (2022). Anti-citrullinated Protein Antibody Generation, Pathogenesis, Clinical Application, and Prospects. Frontiers in medicine, 8, 802934. https://doi.org/10.3389/fmed.2021.802934. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8791387/

Nosal, R. S., Superville, S. S., Amraei, R., et al. (2022). Biochemistry, antinuclear antibodies (ANA). StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK537071/. https://docs.google.com/document/d/18NPnPw1-c-GMulsBKvzsytZuBpvaTWABNgayRC0nGM4/edit

 

 

Strain vs. Sprain = Tendon vs. Ligament

  • Strain – tendon (attaches to the muscle) – 腱 –  overstretch
  • Sprain – ligament (attaches to the bone) – 靭帯 – mechanical injury

Achilles tendon (アキレス腱) Disorders

 

Tendonなので「strain」

Tendinitis/Tendonitis (腱炎) – acute inflammation with swelling – often due to strain or overuse – no tendon damage (S/S: dull aching, swelling, tightness)

Tendinosis (腱鞘炎) – chronic tendon damage due to degeneration – overuse, trauma, osteoarthritis, age – disorganized tendon fibers, scarring, thick, and hard (S/S: pain, burning sensation, stiffness)

(Cleveland Clinic, 2023)

Paratendinitis/paratendonitis – inflammation of adjacent structures (i.g. fat pad), not “surround the tendon.”

Paratenonitis (腱周囲炎) – inflammation of the paratenon (腱傍結合組織、腱周囲） 

 

Ankle Sprain – ligament Injury

Most common – Inversion injury – (Ｏ脚の感じ) – lateral ligament injury, lateral avulsion, lateral fracture

Less common – eversion injury – (Ｘ脚の感じ) – medial side ligament injury – deltoid

Popするような音がしたら、症状は重め。

 

Sprain – Testings & Signs

 

Wrist sprain

Schuck test

Watson test

Shoulder sprain

Empty can or Jobe test

The drop arm test

Ankle Sprain

Talar tilt test

Anterior drawer 

Squeez test

Knee Sprain

Lachman test

Anterior drawer test

Valgus and Varus testing

 

Image Testing

Tendonやligamentは「not radiopaque」なので、X-rayでは見えにくい。Tendon ruptureなど、pathological changeを見たい場合は、imagingはMRIやUltrasoundで。Best seen in ultrasound.

 

Chronic Plantar fasciitisも同様にUltrasoundまたはMRI without contrast (ARC Criteria)。Plantar fasciitis – pain with weight bearing – can be acute or chronic

Morton’s NeuromaもMRI without contrast (ARC Criteria: usually appropriate) またはUltrasound (ARC: maybe appropriate)。Morton’s neuroma – 80% is between 3rd and 4the metatarsal. 20% is between 2nd and 3rd.

Bursitisは、X-rayまたはUltrasound。X-ray is to opt out other conditions or differentiate. To exclude arthritis, foreign body, soft tissue abnormality, joint effusions, gout crystals, or bone pathology.

 

Reference

Cleveland Clinic. (2023). Tendinitis or tendinosis? Why the difference Is important and what treatments help. https://health.clevelandclinic.org/tendinitis-tendinosis-difference-important-treatments-help